Osteopathic practice in the United Kingdom: A retrospective analysis of practice data

Background This study describes osteopathic practise activity, scope of practice and the osteopathic patient profile in order to understand the role osteopathy plays within the United Kingdom’s (UK) health system a decade after our previous survey. Method We used a retrospective questionnaire survey design to ask about osteopathic practice and audit patient case notes. All UK registered osteopaths were invited to participate in the survey. The survey was conducted using a web-based system. Each participating osteopath was asked about themselves, their practice and asked to randomly select and extract data from up to 8 random new patient health records during 2018. All patient related data were anonymised. Results The survey response rate was 500 osteopaths (9.4% of the profession) who provided information about 395 patients and 2,215 consultations. Most osteopaths were self-employed (81.1%; 344/424 responses) working alone either exclusively or often (63.9%; 237/371) and were able to offer 48.6% of patients an appointment within 3 days (184/379). Patient ages ranged from 1 month to 96 years (mean 44.7 years, Std Dev. 21.5), of these 58.4% (227/389) were female. Infants <1 years old represented 4.8% (18/379) of patients. The majority of patients presented with musculoskeletal complaints (81.0%; 306/378). Persistent complaints (present for more than 12 weeks before appointment) were the most common (67.9%; 256/377) and 41.7% (156/374) of patients had co-existing medical conditions. The most common treatment approaches used at the first appointment were soft-tissue techniques (73.9%; 292/395), articulatory techniques (69.4%; 274/395) and high velocity low amplitude thrust (34.4%; 136/395). The mean number of treatments per patient was 7 (mode 4). Conclusion Osteopaths predominantly provide care of musculoskeletal conditions, typically in private practice. To better understand the role of osteopathy in UK health service delivery, the profession needs to do more research with patients in order to understand their needs and their expected outcomes of care, and for this to inform osteopathic practice and education.


Dawn Carnes
AP is a Director at the Institute of Osteopathy, the members' organisation for the UK's osteopathic profession. This study describes osteopathic activity, scope of practice and the osteopathic patient profile in 19 order to understand the role osteopathy plays within the UK health system a decade after our 20 previous survey. 21

22
We used a retrospective questionnaire survey design to ask about osteopathic practice and 23 audit patient case notes. All UK registered osteopaths were invited to participate in the survey. 24 The survey was conducted using a web-based system. Each participating osteopath was 25 asked about themselves, their practice and asked to randomly select and extract data from up 26 to 8 random new patient health records during 2018. All patient related data were anonymised. 27

28
The survey response rate was 500 osteopaths (9.4% of the profession) who provided 29 information about 395   The aim of this study is to provide the osteopathic community, patients, the public and other health 72 care professionals with a descriptive profile of osteopathic practice, the osteopathic patient 73 population and the care they receive from osteopaths. This study will help to formulate teaching 74 goals, plan ongoing continuing professional development activities, identify national research 75 priorities, provide data for stakeholder negotiation and ultimately to optimise patient care. 76

77
Design 78 We used a retrospective questionnaire survey design to: i) ask about osteopaths and their 79 osteopathic practice and ii) audit patient case notes. The survey was a practice review, a type of 80 service evaluation using the principles of audit [12]. The retrospective design meant that we were 81 evaluating actual recorded data, therefore some data may be missing in patient records,. This type 82 of design can help to understand actual practice as reflected by the record keeping of the 83 osteopaths. 84 Selecting patients from both new and returning encounters may lead to an over -123 representation of those consulting more frequently (i.e. those seeking care more often are 124 more likely to be selected), therefore we decided to profile only new patients. 125

Population and setting
To select records, we provided each osteopaths with a random date from 2018, generated by a 126 third-party provider of true random data [16]. Participants were instructed to find the first new 127 patient on or after the provided random date. 128 Anonymity 129 Osteopath anonymity 130 All participants were provided with a unique identifier for use when returning to the survey. The 131 survey database was only consulted where an osteopath forgot or lost their study identifier 132 number. In order to ensure that no unique combination of data could be used to identify any 133 individual osteopath, personal data was collected in ranges. For example, age-ranges were collected 134 rather than ages, and data regarding years in practice was collected in 2-year ranges. 135 Section B of the questionnaire was not linked in any way to section C, thereby reassuring 136 participants that their responses regarding patient care and management could not be used to 137 identify them. 138

139
The separation of part B from part C contributed to ensuring patient anonymity. Directly 140 identifiable patient data was not collected in order to ensure patient anonymity. Osteopaths were 141 asked not to include records where a patient's health might be an identifying factor, e.g. very rare 142 disease. All data was combined and analysed, no individual information is presented in isolation as 143 a case. 144

145
To assure external validity we asked osteopaths, stakeholders and researchers (10 people in total) 146 to comment on and test the questionnaire's face and content validity. For internal validity, we pre-147 tested the software for reliability of health record selection, data entry and data extraction. 148 Sampling and sample size 149 In the previous survey of osteopaths during 2009, a 9.4% response rate was achieved: 342 150 osteopaths participated contributing data about 1,630 patients. For 2019, a representative sample 151 of osteopaths was estimated at 359 from 5,341 registered osteopaths using a confidence interval 152 of 95% with a 5% margin of error). Using a 10% response rate a minimum of 3,590 osteopaths 153 needed to be contacted. However, for the sake of inclusiveness all registered osteopaths were 154 invited to take part as we were asking osteopaths to review fewer patient records than the last data 155 collection exercise (up to 8, whereas in the previous survey we asked for 10). 156 Managing missing data 168 For data extraction from the health records, respondents were given the opportunity to 169 answer 'don't know/can't tell from records'. For other questions, osteopaths were p e r m i t t e d 170 t o l e a v e a n e n t r y b l a n k and provide a text for explanation. Partial data occurred when a 171 participant stopped answering the survey questions before completion. 172 The age profile of patients showed that 53.8% of patients were between 30 and 60 years old. Nearly 212 10% were under 10 years old and of these 4.8% were under 1 years old. 213 Fig. 1  The "other" main presenting complaints were reported as: reflux; overall wellbeing; nerve pain 223 post shingles; clenching teeth; allergies; migraine; ME / CFS; checkup. 224    Overall summary of findings 259 The survey response rate was 9.4%, responders were most frequently aged between 45 and 260 55 years with extensive experience, and were mostly female. The osteopaths worked mostly 261 alone from Monday to Friday and were able to offer about half their patients an appointment within 262 3 days. 263

Co-existing conditions
Patients were typically in their mid-forties and 58% were female. Over half of the new patients 264 had not seen an osteopath before (58%). 265 The large majority of patients (81%) presented with musculoskeletal complaints. 67.9% of these 266 were persistent complaints, and 42% of patients had co-existing medical conditions. 36.6% of 267 patients had received previous treatment or investigations for their presenting episode. Medical 268 general practitioners (GPs) were the most frequent referrals and referrers were to and from GPs 269 (55.6% and 28.6% of referrals respectively). 270 The most common treatment approaches used were soft-tissue techniques, articulatory 271 techniques and high velocity low amplitude thrust. 272 The mean number of treatments per patient was 7 (mode 4). In the decade between this survey and the last and earlier studies on profiles of osteopathic care, 279 patient characteristics have remained broadly similar for adult age profiles, gender and presenting complaints (Burton, 1981;Pringle and Tyreman, 1993;Hinkley and Drysdale, 1995;GOsC, 2001;281 McIlwraith, 2003;Fawkes et al., 2010). The presence of co-morbidities is also similar: in 2019, 282 41.7% of patients reported a range of comorbidities; within this number the most frequent were 283 hypertension (11.0%), arthritis (8.3%), anxiety (5.9%), and asthma (5.1%). This profile is quite 284 similar to that reported in 2009 where patients reported hypertension (11.7%), asthma (6.6%), 285 arthritis (5.7%) and anxiety (3.6%) as the most frequent comorbidities. Previous osteopathic 286 experience remains at around 40%. Self-referral is still the most common route to treatment with The response rate for this survey was not as high as we would have liked but the overall sample 349 size for patients was sufficient for our analysis. We chose a retrospective audit of patient records 350 which may have proved difficult for some clinicians as their records may not have contained the 351 necessary information to complete the questionnaire. However, we thought this may be a finding in 352 itself to highlight areas where record keeping could be improved. Overall the amount of missing 353 data did not highlight any particular area of poor record keeping. 354 We have been able to compare some data from the 2009 and 2019 surveys, and this is the first 355 assessment of this nature within the profession to describe any change over time. 356

357
Other surveys suggest that awareness of osteopathy by the population remains low. An 358 independent survey conducted by YouGov indicated that 57% of people who had not seen an 359 osteopath wanted assurances on a recognised level of education and training, 65% expected good 360 quality advice and treatment, and 90% wanted evidence of effectiveness or recommendation [22]. 361 After the 2009 survey a recommendation was made for the profession to develop a system for 362 independent outcome data collection. This has resulted in the development of the Patient Reported 363 Outcome Measurement (PROMs) system. This system has collected some encouraging outcome 364 data collected directly from patients and independent to the clinician delivering care [23]. 365 Promoting the findings of the PROMs data and information concerning clinicians from the 366 OsteoSurvey 2019 study will start to fill the information gap identified by patients. 367 Profiling osteopaths, their patients and the nature and type of care helps to describe the profession 368 which is useful for providing information for the profession, its regulatory body, its education 369 institutions and its professional body and for informing other health care practitioners about 370 osteopathy. However, more data is needed about patients, to understand their expectations, 371 experiences and outcomes this information would enable practitioners and the profession as a 372 whole to reflect on the nature and type of care they give and its impact on patients. 373

374
The future of the UK osteopathic profession will depend on its ability to adapt to the changing 375 health care needs of the nation. Traditionally osteopaths have filled these gaps for example for 376 persistent pain and other conditions not well managed within the NHS or by pharmaceuticals. 377 There is some indication of flexibility and adaptability which could be enhanced through education, 378 training and active marketing to reflect demographic changes and areas where health service 379 provision is not meeting demand. As the aging UK population grows, demand for care for persistent 380 musculoskeletal conditions and other age related disorders will increase, for osteopathy to 381 maintain and sustain its presence it will need to ensure it offers patients a unique experience and 382 health and wellbeing benefit. 383 To better understand the role of osteopathy in UK health service delivery, the profession needs to 384 do more research with patients in order to understand their needs and their expected outcomes of 385 care, and for this to inform osteopathic practice and education. 386